Municipality of Meaford Covid-19 Screening Assessment

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Every person entering the St. Vincent Community Centre MUST acknowledge that they do not have any of the following symptoms and will have answered NO to the following questions. Should anything change during the season, the Municipality of Meaford asks you to STAY home and contact your local Health unit. For any questions contact Jesse Bedard at jbedard@meaford.ca.

Email *

This form has been supplied by the Municipality of Meaford and is administered through the Meaford Pickleball Club. Your information will be held at the Arena, kept confidential and deleted at the conclusion of the pickleball season at municipal facilities. All players must complete this form prior to stepping on the courts. *

Yes I understand.

Required

You Name *

Your address *

Phone Number *

Date: *

YYYY

#1: Do you have any of the following: Fever or chills? *

Yes

New cough or a cough that is getting worse? *

Yes

Difficulty breathing? *

Yes

Shortness of breath (even when sitting or walking regularly? *

Yes

Sore throat (not due to allergies)? *

Yes

A runny nose or congested nose (not due to allergies) *

Yes

Unusual level of fatique? *

Yes

Unusual headache? *

Yes

Nausea / vomiting, diarrhea, or loss of appetite? *

Yes

Feeling unwell of an unknown reason? *

Yes

Has someone you are in close contact with tested positive for COVID-19? *

Yes

Have you returned from travel outside of Canada in the past 14 days? *

Yes

Do you live with someone who is awaiting COVID-19 tests results who 1) was tested due to symptoms OR 2) was tested due to close contact with someone who tested positive? *

Yes

I hereby certify that the information that I have given here in this form is true. *

Yes

If you are signing on behalf of a child, please add their name here.

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